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Original Investigation |

Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea A Meta-analysis

Soroush Zaghi, MD1; Jon-Erik C. Holty, MD, MS2; Victor Certal, MD3,4; Jose Abdullatif, MD5; Christian Guilleminault, DM, MD, DBiol6; Nelson B. Powell, MD, DDS7; Robert W. Riley, MD, MS, DDS7; Macario Camacho, MD6,8
[+] Author Affiliations
1Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA (University of California, Los Angeles)
2Pulmonary, Critical Care and Sleep Medicine Section, Pulmonary Division, Department of Medicine, Veterans Affairs Palo Health Care System, Stanford University, Palo Alto, California
3Department of Otorhinolaryngology, Sleep Medicine Centre, Hospital CUF Porto, Porto, Portugal
4Centre for Research in Health Technologies and Information Systems, University of Porto, Porto, Portugal
5Department of Otorhinolaryngology, Hospital Bernardino Rivadavia, Buenos Aires, Argentina
6Sleep Medicine Division, Department of Psychiatry and Behavioral Sciences, Stanford Hospital and Clinics, Redwood City, California
7Sleep Surgery Division, Department of Otolaryngology–Head and Neck Surgery, Stanford Hospital and Clinics, Redwood City, California
8Division of Sleep Surgery and Medicine, Department of Otolaryngology–Head and Neck Surgery, Tripler Army Medical Center, Honolulu, Hawaii
JAMA Otolaryngol Head Neck Surg. 2016;142(1):58-66. doi:10.1001/jamaoto.2015.2678.
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Importance  Maxillomandibular advancement (MMA) is an invasive yet effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeletal framework.

Objective  To identify criteria associated with surgical outcomes of MMA using aggregated individual patient data from multiple studies.

Data Sources  The Cochrane Library, Scopus, Web of Science, and MEDLINE from June 1, 2014, to March 16, 2015, using the Medical Subject Heading keywords maxillomandibular advancement, orthognathic surgery, maxillary osteotomy, mandibular advancement, sleep apnea, surgical, surgery, sleep apnea syndrome, and obstructive sleep apnea.

Study Selection  Inclusion criteria consisted of studies in all languages of (1) adult patients who underwent MMA as treatment for OSA; (2) report of preoperative and postoperative quantitative outcomes for the apnea-hypopnea index (AHI) and/or respiratory disturbance index (RDI); and (3) report of individual patient data. Studies of patients who underwent adjunctive procedures at the time of MMA (including tonsillectomy, uvulopalatopharyngoplasty, and partial glossectomy) were excluded.

Data Extraction  Three coauthors systematically reviewed the articles and updated the review through March 16, 2015. The PRISMA statement was followed. Data were pooled using a random-effects model and analyzed from July 1, 2014, to September 23, 2015.

Main Outcomes and Measures  The primary outcomes were changes in the AHI and RDI after MMA for each patient. Secondary outcomes included surgical success, defined as the percentage of patients with more than 50% reduction of the AHI to fewer than 20 events/h, and OSA cure, defined as a post-MMA AHI of fewer than 5 events/h.

Results  Forty-five studies with individual data from 518 unique patients/interventions were included. Among patients for whom data were available, 197 of 268 (73.5%) had undergone prior surgery for OSA. Mean (SD) postoperative changes in the AHI and RDI after MMA were −47.8 (25.0) and −44.4 (33.0), respectively; mean (SE) reductions of AHI and RDI outcomes were 80.1% (1.8%) and 64.6% (4.0%), respectively; and 512 of 518 patients (98.8%) showed improvement. Significant improvements were also seen in the mean (SD) postoperative oxygen saturation nadir (70.1% [15.6%] to 87.0% [5.2%]; P < .001) and Epworth Sleepiness Scale score (13.5 [5.2] to 3.2 [3.2]; P < .001). Rates of surgical success and cure were 389 (85.5%) and 175 (38.5%), respectively, among 455 patients with AHI data and 44 (64.7%) and 13 (19.1%), respectively, among 68 patients with RDI data. Preoperative AHI of fewer than 60 events/h was the factor most strongly associated with the highest incidence of surgical cure. Nevertheless, patients with a preoperative AHI of more than 60 events/h experienced large and substantial net improvements despite modest surgical cure rates.

Conclusions and Relevance  Maxillomandibular advancement is an effective treatment for OSA. Most patients with high residual AHI and RDI after other unsuccessful surgical procedures for OSA are likely to benefit from MMA.

Figures in this Article


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Figure 1.
PRISMA Flow Diagram

The meta-analysis included 518 unique patients undergoing 518 unique procedures. CPAP indicates continuous positive airway pressure; MMA, maxillomandibular advancement; and PSG, polysomnography.

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Figure 2.
Forest Plot of the Meta-analysis of Maxillomandibular Advancement (MMA) Studies With Individual Patient Data

Differences in the apnea-hypopnea index (ΔAHI) and respiratory disturbance index (ΔRDI) outcomes are shown as means (data markers) with 95% CIs (error bars) to include 2 SEs from the mean. The references are ranked in descending order of sample size. Results demonstrate a symmetric inverted funnel shape and reflect a data set for which publication bias has been minimized.

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Figure 3.
Change in Apnea-Hypopnea Index (ΔAHI) by Preoperative AHI Severity

Four hundred fifty-five patients had AHI data. Mean differences are displayed for each preoperative AHI cohort. A direct linear correlation between preoperative AHI and ΔAHI is seen (R2 = 0.84; P < .001) (ΔAHI = 3.76 − [0.90 × preoperative AHI]). Patients with more severe preoperative AHI values experienced the greatest magnitude of reduction in the postoperative AHI. The mean ΔAHI of the preoperative AHI cohort with fewer than 30 events/h was −14.1 (11.6) events/h compared with a mean ΔAHI of −94.5 (23.5) events/h for the preoperative AHI cohort with 60 to fewer than 90 events/h.

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